On Death and Dying
On Death and Dying
By: Elisabeth Kübler-Ross
Source: Elisabeth Kübler-Ross. On Death and Dying. New York: Macmillan, 1969.
About the Author: Elisabeth Kübler-Ross (1926–2004) gained fame in the 1970s for developing a theory concerning the stages and psychological impact of death and grieving. Her ideas are credited with making possible the mainstream public acceptance of the hospice movement in the United States.
In the course of her practice at major hospitals in New York, Colorado, and Chicago, Elisabeth Kübler-Ross was appalled by what she saw as the standard treatment of dying patients, who in her view were shunned and deceived. She began sitting with these patients, particularly pediatric cases, encouraging them to talk to her about their feelings and concerns. She observed that there were several common themes in the experiences and emotions of dying people, and started a series of lectures on her ideas and the theory of grieving that she developed based on her interviews with patients. She was able to persuade some of the terminally ill, such as the seventeen year-old girl with aplastic anemia featured in the excerpt, to discuss their experiences and thoughts in a group setting that included other medical professionals and students. Her work with and lectures about the dying were revolutionary, and brought about more inclusive and compassionate treatment of the terminally ill by the medical profession and society as a whole.
On Death and Dying, derived from her lectures and published in 1969, was a best-selling first book and secured her fame worldwide. It continues to be required reading in many medical, nursing, and psychology programs. The five psychological stages of dying that she described in the book (denial, anger, bargaining, depression, and acceptance) became part of the popular understanding of death and grieving across the world.
The stages of dying that Kübler-Ross formulated are: 1) denial and isolation, in which patients and families temporarily protest against the bad news of impending death; 2) anger at being singled out for death by God or at being singled out for death instead of others that might deserve death more; 3) bargaining, in which the patient hopes to postpone death until some goal is met; 4) depression characterized by mourning for the losses of relationships, profession, and possessions; and 5) acceptance of the inevitability of death and cessation of the emotional struggle against it.
The following excerpt from Elisabeth Kübler-Ross's book On Death and Dying is a transcription of one of her interviews with a terminally ill patient. In this interview, the patient described her most intimate feelings about the experience of dying.
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Elisabeth Kübler-Ross studied dying and grieving in the context of an American society often characterized as unwilling to face and accept death, and prone to avoiding contact with the dying. It should probably not be unexpected that this culture spawned such a systematic and empirical approach to the study of death and dying, which then opened the way to a more accepting emotional connection to terminally ill patients. Her practice of providing palliative treatment and companionship to dying patients also led to the widespread provision of hospice care to provide more dignified handling of patients' final hours.
Since Kübler-Ross's work became dominant in the study of death and dying, several other approaches to the field and critiques of her methodology and conclusions have arisen. Other investigators such as Robert Kastenbaum have questioned the assertion that people go through stages in the sense that an ordered set of conditions are present in coping with death. In reviewing Kübler-Ross's cases he found that while patients exhibited emotions that characterized the five stages, none of them went through all of the five stages in order. While he grants that Kübler-Ross's interview methodology was a good qualitative starting point for research, he maintains that it should have been followed up by more systematic and quantitative data gathering. Qualitative, open-ended interviewing is a useful exploratory research technique, but is subject to bias based on the relationship between the interviewer and subject as well as bias based on what a subject might choose to reveal.
That Kübler-Ross's theory became so famous is also problematic, because people came to see it as prescriptive rather than descriptive. Patients might feel pressured internally or by relatives to reach the final stage of acceptance of death, which might be seen as the only way to die properly. Also, the uniqueness and accomplishments of each patient's life could be overlooked and become subsumed in this rather generic sequence of stages that are supposed to take place in the final weeks or months of life. Critics have particularly focused on this tendency of Kübler-Ross's ideas to underestimate the extent to which the uniqueness of each individual tends to shape feelings, experiences, and personal development at and near the end of life.
From another perspective, William McDougall, founder of the field of social psychology, saw the process of dying as being one of personal growth rather than one of protest and resignation. In McDougall's view, dying is the last in a sequence of significant experiences in life that needs to be intellectually integrated into one's view of self and the world. His ideas appear to have influenced some of Kübler-Ross's later thinking and writing.
Kübler-Ross thrived on the pioneering aspect of her work and the notoriety that it gained her, and was a prolific writer and active with dying patients until she experienced a series of disabling strokes prior to her death in 2004. She was frustrated that disability intervened to prevent her from being in control of the circumstances of her own death after having helped so many patients to accept their deaths. Also, Kübler-Ross stated that the strokes prevented her from coming to grips with what she saw as the mystery of death and life after death.
In spite of its scientific shortcomings, the work of Kübler-Ross has had a profound impact on medical practice and the care of the dying by both health care professionals as well as by nonprofessional and family caregivers. It has been instrumental in helping Western society to face death squarely and stop avoiding it both as a topic of discussion and in resisting involvement with dying people. It is not clear, however, that society is any closer to an actual acceptance of death. This is, perhaps, what Kübler-Ross herself was attempting to find as she explored the experiences of resuscitated patients, including the "bright light" and the "tunnel" toward which they reported being drawn as they were at death's door.
Beauchamp, Tom, and Robert Veatch, eds. Ethical Issues in Death and Dying. 2nd edition. New York: Prentice Hall, 1996.
Kastenbaum, R. J. Death, Society, and Human Experience. 6th edition. New York: Allyn and Bacon, 1998.
Kübler-Ross, Elisabeth. On Grief and Grieving. New York: Scribner, 2005.
Kübler-Ross, Elisabeth, and David Kessler. Life Lessons: Two Experts on Death and Dying Teach Us about the Mysteries of Life and Living. New York: Scribner, 2000.
Elisabeth Kübler-Ross. 〈http://www.elisabethkublerross.com〉 (accessed November 23, 2005).
Film Monthly. "Facing Death: Elisabeth Kübler-Ross (2004)," by Kristin Schrader. 〈http://www.filmmonthly.com/Video/Articles/FacingDeath/FacingDeath.html〉 (accessed November 23, 2005).